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SAN 7oAQL.r._N r cm A.L HwALrrm =s^rm I= <br /> UNDERGROUND TANG DISPOSITION TRACKING RECORD <br /> RR}}fflRAf ttttRt#tett!#tt!#Rt!*ttttt!lRtRhtt!!tt!!!tlRt*ltt tflAR*t*htR#*###tt*Rt Af t*t!lRt R! <br /> M. O N 1 - The San Joaquin Local Health,District's Tracking Sheet will accompany each tank <br /> affixed with its site identification nurber. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> racyCIIng facility. The holder of the permit with number noted below is responsible for <br /> aosurim that this fora is cgWleted and returned <br /> FACILITY NAME: Henry Wolters & Son - Charlie Skobrak <br /> FACILITY AOORESS. 331 N. Aurora, Stockton , CA 95202 <br /> TANK ID 139- ? �// S - 1 - 5,000 gal . tan <br /> L � [PA Site # CAC 000195873 <br /> f!RlRet!!RtlRt!lRttR*t!!tltth*RRRt*ttttRh*RthhRt*!!lRtht**ttRtlf tett*tlRtRRhttttttRtltRtlt! <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorpe Oil , Inc. <br /> Address: 351 N. Beckman Road , Lodi , CA Zip: 95240 <br /> Phone#: 1 209) 4E2-4581 <br /> Tre lephone: ( ) Date Tank Removed: f 0/Czo � <br /> RRRttRttttRtt##tRtltlRtltttt**tRRRlt!!tR!**R!t!R*R!!tR!!!tltttRtRtf Rttltttt!ltttttlt!}ftttR <br /> SK TION 3 -To be filled out by contractor "decontaminating tank": <br /> 'tank Decontamination" Contractor: Jim Thorpe Oil , Inc. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Berkman Road , Lodi , CA Zip: 95240 <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be r �t�ed by Department of Health Services. <br /> � TIRLE 11-:7 <br /> RRR*tt Rf t!!R#Rtt#Rt*ltRRRlRRRttlRtlRltRltR!ltRRRR*tet*R*!*lthRRRR!*hRR!!!ltRt*t!t##**hRtttt <br /> SW TION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name. <br /> Address: nuf T, C .. <br /> LAI71T2�IR 9T�E6 Mr` Zip: <br /> SOM BLVD. Phone#: <br /> OVARANCHO CORD5_a810 y _ <br /> Date Tank Received: <br /> j <br /> AUPTWW <br /> IZED SIGNATUft AND TITLE <br /> ttR}}tRlttt#tlttttt!ltttttlRlRtlRtlhRtRRttRRRlRtRtRtRttRRtttt!!t!!RlRttttRttRttR!ltttRlR!!t <br /> RH 23 019 11/81 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAUUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STDCKTON, C1 95202 <br />